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In December 2022, the National Institute for Health and Care Research (NIHCR) reported that misconceptions about acne and eczema can be a barrier to the effective management of these common skin conditions.
Many people often don’t realise they need long-term treatment, leading to frustration and disappointment. According to the NIHCR, community pharmacists are well-placed to help people understand what to expect from acne and eczema treatments and signpost them to reliable sources of information.
“Community pharmacists can be of tremendous help with early diagnosis, as many times people will go to their local pharmacist for advice before they head to their GP,” says Dr Stephanie Gallard of the British Association of Dermatologists (BAD)’s Pharmacy Workstream.
“Beyond this is the role a community pharmacist plays in suggesting OTC measures and supplementary care. It is very important for people with skin conditions to get their skincare regimen right, which will help to prevent further harm to their skin.”
Expanding pharmacy’s role
Sunil Kochhar, a pharmacist and cosmetic and dermatology independent prescriber, says that community pharmacists are ideally placed to encourage self care, signpost customers to information sources, or refer accordingly. “Clinical examination is key in skin conditions, so it’s important for pharmacists to know the red flags and warning signs,” he says.
“Pharmacists aren’t used to ‘feeling skin’, as that’s not how they’ve been taught. They’re used to asking questions and responding to symptoms. But pharmacists can ask their customers to show them their skin in the consultation room, and can even be trained to use a dermatoscope to magnify the skin. Pharmacists may worry about potential issues such as missed cancers, but training courses are available.”
There are many ways for community pharmacists to expand their dermatology knowledge. Health Education England has included a dermatology module in its Clinical Examination Skills Training for Community Pharmacists’ Winter 2022/2023 offering, with the training being delivered until March 2024. The BAD website directs pharmacists looking to expand their knowledge to the Medway School of Pharmacy’s dermatology module. “My recommendation to pharmacists interested in skin would be to read as many online resources as they can, attend as many educational events as possible, and join any societies relevant to their interest,” says Dr Gallard, adding that BAD and the Primary Care Dermatology Service are good places to start.
Mr Kochhar has used his own knowledge and experience to co-found Forever Mountain (www.forevermountain.co.uk) to support independent prescribers to build, grow and scale successful private dermatology clinics. Forever Mountain also runs free educational events for community pharmacists with an interest in dermatology.
“Paying for courses takes time and money and is a big investment,” says Mr Kochhar. “When seeing sales reps, pharmacists can ask if they have free educational events and materials. OTC emollient companies support education, and prescription-only lines have free training and webinars. Independent prescribers can expand on their knowledge even further, going beyond what’s available in retail.”
Treatment advice
When advising on suitable skincare treatments, it’s important that pharmacy teams take a holistic approach. Most chronic skin conditions flare up and then subside, with triggers varying from person to person.
Helga Mangion, NPA’s policy manager says it’s important to take a tailored and personalised approach to each patient, especially considering the impact skin conditions can have on a person’s confidence.
Laura Ball, brand and marketing manager for MooGoo Skincare UK, says pharmacists should consider how mental health and lifestyle factors may be having an impact on skin condition flare-ups. “Factors such as stress, anxiety and the weather can have a huge impact in someone’s skin,” she says.
Mr Kochhar recommends understanding the local community when speaking to customers about flare-ups. “We have a large Sikh population,” he says. “Many wear their turbans too tightly, which can cause contact dermatitis if the fabric rubs against their skin. In the summer, they may be prone to fungal infections.”
Healthy skin at the menopause
A British Skin Foundation survey has found that although 85 per cent of people experience some skin changes during the menopause, 24 per cent of survey respondents felt embarrassed to discuss it. Menopausal skin changes can include excessive dryness, laxity of the skin, excessive signs of ageing, alterations in pigment, rosacea or broken blood vessels, and late-onset acne. Three quarters of dermatologists surveyed stated that menopausal skin requires a change in skincare products to coincide with the skin changes. Useful skincare tips to pass on to pharmacy customers going through the menopause include:
- Wash with a mild, soap-free cleanser or emollient
- Use a rich moisturiser daily on the face and body
- Use a topical retinoid product at night
- Use sunscreen daily, for all skin types.
Types of skin conditions
According to research published in the BMJ Open journal in January 2021, people with acne often view their condition as short-term and not requiring long-term treatment, and many people still consider the condition to be a ‘normal’ part of adolescence.
“It’s important that people know the facts about acne so they can understand it and, ultimately, treat it better,” says Angela Jones, brand manager of Acnecide and Purifide. “When you understand acne, you can choose a routine that can support your acne-prone skin, without wasting time and money on things that are unlikely to work and just lead to a feeling of disappointment or guilt.”
Many people mistakenly believe that acne is caused by a poor diet, lack of cleanliness or poor hygiene. “Clinical trials confirm that acne is more down to hormones and genetics – for example, the makeup of the microbiome and size/density of your oil glands, which is hereditary,” says consultant dermatologist Dr Anjali Mahto.
“Diet can play a role, but not in the instantaneous way that some might think,” says Dr Mahto. “People with acne are very aware of hygiene and are more prone to over-washing or cleansing, which can make things worse.”
Dr Derrick Phillips, consultant dermatologist and British Skin Foundation spokesperson, says that it’s easy for patients, and even clinicians, to get confused about the wide range of available products. He recommends highlighting the following ingredients (in no specific order): benzoyl peroxide, niacinamide, azelaic acid, retinol/retinaldehyde, vitamin C and salicylic acid.
“If acne doesn’t improve with over the counter treatments, medical assessment and treatment is warranted to prevent scarring,” he says. “This is particularly important in patients with nodulocystic acne and patients with skin of colour.”
Community pharmacists can help customers with the management of acne by providing advice on skincare regimes. “Explain non-comedogenic skincare (including emollients),” says Dr Gallard.
Emollients are the cornerstone of eczema treatment. “If a patient isn’t comfortable applying an emollient regularly or is concerned about using too much due to the cost, it isn’t the right emollient for them,” says Dr Gallard. “Always check if a patient needs or has a pre-payment certificate. This can make a huge difference to patients with chronic inflammatory conditions, in particular, who should be getting their emollients on prescription.”
Mr Kochhar says there is a lack of knowledge about how to apply emollients properly and also how to use them safely. “If emollients make contact with clothing, this can become a fire risk,” he says. “If they are used in the bathroom, it’s important to prevent falls.”
Community pharmacists also need to advise on the correct use of topical steroids. “Topical steroids are safe and effective when used correctly under appropriate supervision, and topical steroid withdrawal is uncommon,” says Dr Phillips. “It is more common to see active eczema being under-treated due to anxiety regarding topical steroids. This often leads to more prolonged and severe flares that inevitably require stronger treatment.”
In September 2022, a study by the University of Manchester, published in the British Journal of General Practice, found that psoriasis is often misdiagnosed as other skin conditions such as eczema or fungal infections, and opportunities for early diagnosis are often missed.
Community pharmacists should be aware of the key psoriasis symptoms (dry skin lesions, known as plaques, covered in scales) and how they appear on different skin colourings. On brown, black and white skin, the patches can look pink or red, and the scales white or silvery. On brown and black skin, the patches can also look purple or dark brown, and the scales may look grey.
Psoriasis treatment depends on the type and severity of the psoriasis, and the area of skin affected. “As a first-line treatment for mild to moderate psoriasis, there are numerous different topical creams and ointments available,” says Kenny Chan, Numark lead information pharmacist. “Some of these may need to be applied several times throughout the day. Often, this involves patients using steroid creams – which come in various strengths and can only be used short-term. For long-time sufferers, those who can’t use steroids and for patients who are unable to apply throughout the day, these creams and ointments may not be suitable and a referral to a doctor may be required.”
In August 2022, a British Skin Foundation survey found that while the over-50s are aware of the importance of wearing sunscreen abroad, they may neglect to use it whilst in the UK.
“It is a myth that sun exposure in the UK is less harmful than holiday sun,” says Dr Phillips. “Prolonged sun exposure without sunscreen can lead to sunburn, sun damage and, ultimately, skin cancer – whether it’s in the UK or abroad. It is therefore important to regularly apply high factor sunscreen (SPF 30+ with 5-star UVA protection) during hot UK summers, as you would if you were abroad.”
Mr Kochhar says that when talking about sun protection, it’s important to discuss anti-ageing as well, especially with younger age groups. “Many people are concerned about how their skin looks, and this can affect their confidence and mental health,” he says. “This has been heightened with the use of Zoom calls in recent years. When talking about sun protection in the pharmacy, this can also open up other conversations, such as about smoking and how free radicals can damage the skin.”
Views from the P3pharmacy panel
This is an important area for us, especially for eczema and dry skin conditions. Other popular areas are fungal rash, Athlete’s Foot, warts, verrucas and fungal nail infections. Our main source of queries are eczema and dry skin. Popular brands for eczema include Aveeno, E45, Diprobase and Double Base. For fungal infections, top sellers include Daktarin, Canesten AF and Daktacort HC. Eumovate and Eurax do well for skin conditions too. For warts and verrucas, we tend to recommend a salicylic acid treatment first, such as Bazuka, and if this doesn’t work then a freeze treatment such as Wartner.
Hardik Desai, Ticehurst Pharmacy, East Sussex
Dry, scaly and inflamed skin conditions are so prevalent given our climate here in the UK that I think this category will remain a prominent topic in pharmacy. A lot more patients are leaning towards non-steroidal topical therapies now. Customers ask us which creams are available on prescription, how long to use steroids for and if there’s any way to prevent flare ups of conditions. Zeroderma, Aveeno and Oilatum do well for us. There’s a larger interest in natural remedies versus steroidal/chemical products. Order samples – allow customers to trial creams and see what suits them before they buy.
Marisa Maciborka, Well Pharmacy, Hirwaun
Skincare is a big category for us, from child to adult general care, to acute dermatitis treatments. It has seen a big increase since we established better links with the local surgery, which is referring patients through the CPCS. We now stock the QV range, which offers us a means to tackle all stages of dry skin. The formulations contain neither lanolin nor propylene glycol, so offer a fresh approach to drive customer loyalty. The CPCS has brought a new stream of patients to us. It’s imperative to stock at least one whole range so the customer can understand the various options.
Gareth Evans, Wansford Pharmacy, Peterborough
Scar management
Scars are a natural part of the healing process, but can affect people both physically and emotionally, especially if they take a while to fade. There are several different types of scars:
- Minor cuts often leave thin, raised lines that will gradually flatten over time
- Keloid scars develop when too much collagen is produced at the site of a wound. These are raised and keep growing, even after the wound has healed. They are often itchy or painful and may restrict movement
- Hypertrophic scars are also caused by excess collagen. They don’t get larger, but they may continue to thicken for up to six months before improving over several years
- Sunken or pitted scars can be caused by skin conditions such as acne or chickenpox.
Scars can’t be removed completely, but treatments can usually make them less visible. Management options include topical silicone gel or silicone gel sheets, pressure dressings, steroids, skin camouflage (make-up) or surgery.
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